Perspectives from Paramedics Responding to Deaths by Suicide

Article in Review: Nelson, P., Cordingley, L., Kapur,N., Chew-Graham, C., Shaw, J., Smith, S., McGale, B. and McDonnell, S. (2020). ‘We’re the First Port of Call’- Perspectives of Ambulance Staff on Responding to Deaths by Suicide: A Quantitative Study, Frontiers in Psychology, DOI: 10.3389/ipsyg.2020.00722

Summary: The impacts of responding to death by suicide is complex, yet predictable. Paramedics should be afforded support via workplace systems specifically designed to mitigate the impact of suicide related trauma exposure, particularly when the death by suicide relates to a person known to the Paramedic.

Notes: SRAA acknowledge that the findings of this research appear obvious, given the psychosocial hazards that commonly underpin workplace psychological injury and the impacts of exposure to trauma. What is often less recognised or accepted, is that Paramedics are not ‘immune’ to the impacts of trauma exposure. Some employers have demonstrated the expectation that employees ‘accept’ the inherent requirements of a role, including responding to suicide attempt and death by suicide. Whilst this is to some degree true, it is an inherent requirement of the role, how an employer equips a person to commence their employment with full understanding of potential impacts and how they understand their own psychological strengths and vulnerabilities, opportunities to recognise and mitigate foreseeable exposures and appropriately respond to psychosocial hazards including trauma exposure, remains lacking. This research, is the start of more considered exploration of the unique demands of suicide specific trauma exposure, psychological injury prevention and appropriate care for an essential workforce.

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As ﬁrst responders, Paramedics will likely attend multiple deaths by suicide events during the course of their working lives. This may include, on occasion, the death of people known to them. Responding to suicide will impact officers in different ways, and be dependent on a number of situational factors. Numerous studies indicate that Paramedics experience higher rates of absenteeism, raised mental health morbidity, distress and more frequent suicides and suicide attempts than the general population, and also in comparison to employees from other health related fields.

A voluntary qualitative study (Nelson, et al., 2020) was undertaken in North-West England, to help better understand the suicide-related perspectives and experiences of Paramedics. The findings are deemed by researchers as transferrable to other ambulance services. It should be noted that some aspects described by the research, including the professional response to the impact of responding to the death of a colleague by suicide, the relationships between medical staff and first responders etc., has not been explicitly considered from an Australian context and SRAA therefore suggest caution in how these findings are interpreted.

There are high expectations on ambulance staff when they attend a death by suicide. They may encounter other bereaved or volatile individuals at the scene of a suicide or may be required to inform family members of the death of a loved one. Attending a death by suicide where the person was either directly known to them, or known by association, causes particular distress. The fact that suicide rates are higher in professions that deal with trauma means an ambulance officer could even be called to attend the death of a colleague. Paramedics also mentioned the particular distress of attending a death by suicide when they identified in some way with the deceased; such as their having a child of the same age. One described to having their thoughts “haunted” by the long term, salient memories of attending a death by suicide.

Themes identified in the study included;

A profession under strain

They reported high expectations regarding their responsibility and a lack of respect for their work
A systemic lack of understanding about their role and of the impact of the role emotionally

“They just seem to think we’re on autopilot… nothing bothers you, nothing affects you… I think they see us as real hard… very hard people and we’re not…” (Paramedic)

Responding to to the loss of colleagues by suicide during their career was noted in the research as as ‘not uncommon’. Nelson et al., (2020) wrote that Paramedics felt the need to conceal their distress due to the pressures of their role and needing to continue to service the community

“… we’d come in on the shift and we were told [about the colleague’s suicide], and basically you manned your ambulance and went out. If you didn’t go… then there’d be no ambulances going out there. So you’re just… well, like robotic. You just went out” (Paramedic)

Responding to suicide in a professional capacity

Responding to suicide was noted to be a ‘daily’ aspect of the role and could be more emotionally demanding than attending accidents and traumas
Paramedics experience distress and vulnerability caused by the exposure to suicide, particularly if they relate to the deceased, or to the grief of those impacted at the scene

“People… will come back to the station… they ring home and make sure everyone is all right, you know, because that’s how it affects you” (Paramedic)

They described feeling ‘conflicted’ and ‘in danger’ when responding to suicidality and crisis, which was associated with feeling unprepared and ill-equipped to manage psychological crisis

“… Well, I just sat there and thought ‘God, what am I gonna do here? What…? [He said he] didn’t want to die, but he said he’d got somebody sitting here telling him to go and do it…” (Paramedic)

Paramedics described the pressure of ‘multi-tasking’ in working to resuscitate a person, calm the relatives and prepare for transportation to hospital.
Conflict in roles was also described with respect to preserving a potential crime scene whilst also aiming to save a life, complicated by confirmed deaths and extended waits for police to arrive at the scene of a death amidst the volitile responses of family. Emotional responses described in this context, included hopelessness, helplessness and a duty to protect the loved ones from the trauma of suicide loss. These factors were further complicated by feelings that other services (such as police) could show “more respect for bodies of the deceased and for the bereaved…” (p.6)
Paramedics described feeling ‘blamed’ for being unable to resuscitate a loved one

Lack of workplace support

Paramedics described feeling a lack of acknowledgement regarding the impact of suicide exposure, which included “manning up”

“…there’s a lot of new staff coming on… and some of them might be a little bit nervous to say ‘I’ve just seen something and I can’t deal with that’…” (Paramedic)

“…the unfortunate part [is]… if you can’t cope with the stress, you shouldn’t be in the job. There’s no such thing as stress in the ambulance [service]” (Paramedic)

In responding to and managing the impacts of suicide on Paramedics, the researchers noted that overwhelmingly, Paramedics described ‘the onus was on staff themselves to look out for signs of distress in other colleagues’ (p.7)
Support offered through the ambulance services was described as ‘lip service’ or ‘tick box’ and underpinned why Paramedics were reportedly reluctant to access it. This also related to concerns about confidentiality and colleagues having access to their private information.

The authors noted

“…staff commented that the lack of training in how to respond to people who were bereaved by suicide was surprising because attending these kinds of deaths was such a common part of the job… [and] staff had no knowledge of how to respond to colleagues who had themselves been personally bereaved by suicide” (Nelson, et al., 2020, p.8)

Additionally,

The research described Paramedics considering themselves as unpopular with other medical professionals, because they have the task of bringing more patients to hospital and increasing the workload of other medical staff in the hospital setting, and this complicated perceptions of workplace support, when responding to the suicide attempt
A tension was also indicated through the study, in relationships with staff from non-medical professions, such as the police, given the above experiences

In summary

The research described expectations on Paramedics to take on responsibilities beyond the medical, including providing social support and advice at the scene of non-fatal suicide attempts, as well as interacting with distressed family members or bystanders. Paramedics may find themselves in highly volatile and complex situations when attending a death by suicide, including the person being a colleague or friend, managing their own emotional responses and making decisions to protect the emotional wellbeing of bereaved families. Further, they are also expected to act as “custodians of a potential crime scene” which may result in lengthy delays at the scene of a suicide.

There is a great deal of room for improvement described by the research, specific to the trauma of attending a suicide, and how we support Paramedics who conduct this work.

Opportunities for improvement

First and foremost, researchers stated that employers must recognise that suicide-related work is likely to have an impact on the wellbeing of their staff.
Employers have a duty of care to support Paramedics who experience stress and trauma at work, which includes unique impacts of suicide exposure.
Opportunity for quality debriefing meetings and scheduled breaks should be provided.
Paramedics should have access to professional emotional support services, without having to worry about their privacy or damage to their reputation.
Greater promotion of self-care in the workplace is also suggested, including beyond the identification by individuals.

The situation in which there is an existing relationship or association between officer and the person who has died needs to be prepared for through specific policy and procedure around this occurrence. There are also opportunities in the area of training, through the provision of continuous refresher training in suicide intervention and skills for coping with trauma related stress. Training from other disciplines, such as critical incident management training, could also better equip Paramedics to respond to the complex circumstances they encounter.

By shining a light on the experiences of Paramedics, by recognising the unique and complex situations they encounter, by supporting them with training and psychological care, and creating space for them to reflect and debrief, we can better support them to conduct the essential work they do in our communities.